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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �A �2�43�1P S2a71�1y0 <br /> OWNER f OPERATOR <br /> �� .^^ CHECK If BILLING ADDRESS <br /> FACILITY NAME A A to C r'✓ t <br /> et- Mg <br /> SITE ADDRESS 'I, ( 7 c 1"l I n �([/ L �., ice..L r;r-ni•y-1 <br /> StreetNu Direction Street Name -- CI n Cod. <br /> HOMEoror MAILING ADDRESS (Ii Different from Site Address) <br /> 1J 20 C Street Number /�yG/' Street Name <br /> TAT <br /> CIN ? b l_.'"lE - <br /> P510,;2 <br /> .HHOONE#1 Exr. APN# LAND USE APPLICATION# <br /> 510 d / J22 1 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> /_ {.O e^ ' � �. ,r CHECK If BILLING ADDRESS <br /> BUSINESS NAME M/'/ln �(/( J!t/` PHONE# T. <br /> HOME or MAILING ADDRE S <br /> 326 c c�cr fiUG FAX# ) <br /> CITY LSb CAST E ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagentof same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this applipa' n and that the wor performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard-ai' nd FEDERAL laws. <br /> / l / <br /> APPLICANT'S SIGNATU(t� _ � DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and atPygij[Dflt!'Ve_it Is provided to me or <br /> my representative. AYMENT <br /> TYPE OF SERVICE REQUESTED: TbcdMt:W, D-11 , EIVED <br /> COMMENTS: CVt(Avw e � JUL 17 2018 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: - ,,11 EMPLOYEE#: DATE: •�_' <br /> ASSIGNED TO: 1-Y 1 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 4 (y17 1 <br /> Amount Paid - Payment Date 7 I47i 1 <br /> Payment Type �, �— Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />